Asian Journal of Pharmacy and Pharmacology 2017; 3(6): 224-228 224

Research Article
Pharmacoeconomic evaluation of Antisecretory drugs in Tertiary Care Hospital
Anagha Dhore, Karandikar Y. S.*, Vaibhav Hanumant Khutle, Shreyash Madankar, Nishant
Tangadi, Rohan Bhagat
SKN Medical College & General Hospital, Pune, Maharashtra, India

Received: 25 October 2017 Revised: 14 November 2017 Accepted: 23 November 2017

Abstract
Background: Indian drug market is flooded with many drug formulations of antisecretory drugs. The volume of
prescribing antisecretory drugs has had a substantial impact on prescribing expenditure worldwide.
Pharmacoeconomic research focuses on providing quality care within limited financial resources. Objective: The
purpose of this study was to perform Pharmacoeconomic evaluation and determine cost saving measures in the
treatment of patients with conditions requiring antisecretory medications. Materials and methods: We conducted a
prospective observational randomized active control open label study. Cost effectiveness ratio for Ranitidine and
Pantoprazole was calculated by dividing the cost of treatment by it's clinical outcome (FSSG score) . Cost
minimization analysis was done with three proton pump inhibitors available in the hospital pharmacy assuming that
they have equal efficacy as well as from the patient's perspective (pocket payments ) in accordance with the cost of PPIs
available in market (over the counter). Results: In our Hospital, pantoprazole was the most commonly prescribed
drugs. The mean improvement score with pantoprazole was 6.27, while in ranitidine group it was of 1.96. The cost of
reducing 1 unit FSSG score per day was Rs.0.12 with Pantoprazole and 0.32 with Ranitidine. Cost minimisation
analysis showed that Omeprazole is the most economical treatment among available PPI in hospital pharmacy as well
as PPI available in market. Conclusion: Pantoprazole was found to be more cost effective drug than Ranitidine as per
the price of drug available in Central Hospital Pharmacy. Amongst all PPI , substitution by Omeprazole would be
expected to produce cost savings .
Keywords: Pharmacoeconomic evaluation, Pantoprazole, antisecretory drugs, FSSG score

Introduction
Inevitable changes in the lifestyle and food habits of Indian
population along with excessive use of medications are the
reasons for increased gastric acid secretion. This leads to
gastroesophageal reflux disorder (GERD), ulceration ,
esophagitis ,erosive gastritis ,etc. Dyspeptic symptoms are
common in the general population and affect about 25- 54 %
adults in a year (El-Serag et al., 2004). All these changes further
leads to rapid rise in use of antisecretory drugs.
Antisecretory drugs constitute about 4-11% of total medical
budget (Westbrook et al., 2001). High volume of prescribing
these drugs may reflect the high efficacy and less adverse
drug effects. Proton Pump Inhibitors are among the top ten
bestselling drugs. They are the most prescribed drugs in
India. Over 1000 brands of antisecretory drugs are available
with significant difference in their costs(Current Index of
Medical Specialties 2016; Drug Today, 2017). The
antisecretory drugs mostly used in India are pantoprazole,
omeprazole, rabeprazole, lansoprazole, esmoprazole,
ranitidine, famotidine, etc. The proton pump inhibitors and
H2 blockers have equivalent efficacy at comparable doses.
Though there is similarity in efficacy and safety of these
drugs, there is significant difference in their costs.

*Address for Corresponding Author: Considering the above factors , a pharmacoeconomic

Dr. Karandikar Y. S. research of antisecretory drugs was conducted.
Associate Professor, SKN Medical College & General Hospital, Pharmacoeconomics is a branch of health economics which
Pune, Maharashtra. India. particularly focuses upon the costs and benefits of drug
Email: karandikar_yogita@yahoo.com therapy (M.Kiran Babu et al., 2014). It provides quality care
Phone No: +91-9922747908 within limited financial resources and helps to make

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 Asian Journal of Pharmacy and Pharmacology 2017; 3(6): 224-228 225

decision when various drugs are available. It reduces the cost

burden and increases patient compliance.

There are four main techniques used in pharmacoeconomic

assessment :Cost minimization analysis, Cost effectiveness
analysis, Cost benefit analysis, Cost utilization analysis
(Kulkarni et al., 2009).
Cost minimization analysis and cost effectiveness analysis was
used in this study. The objective of this study was to determine
the cost saving measures in treatment of patients with
conditions requiring antisecretory medication.

Materials and methods

The method used in our study was Prospective Observational Figure 1. Graph1:Percentage of brands of antisecretory
Randomized Active Control Open Label Study in a Tertiary care drugs(n=808
hospital for a period of two months with a sample size 200. The
Table1. Use of antisecretory drugs per Department
patients included were of either gender, more than 18 years of
age, admitted to the Medicine, Orthopaedics, Surgery and Department Pantoprazole Ranitidine Pan D Others
Gynaecology wards prescribed with antisecretory drugs and
were willing to participate in the study. Orthopaedics 44 6 0 -
Surgery 48 1 2 1
The pharmacoeconomic parameters used were:
Medicine 37 5 7 2
1) Number and cost of PPI brands available: which was
Gynaecology 4 46 0 -
collected from CIMS and Drug Today (Current Index of
Total 130 61 9 3
Medical Specialties, 2016; Drug Today, 2017).
65% 30.50% 4.50% 1.50%
2) Cost Minimisation Analysis (Kulkarni et al., 2009) was
carried out as per Hospital Pharmacy and patient's
perspective, that is, pocket payments and over the counter Amongst all the antisecretory drugs ; Pantoprazole was the
drugs. It is the simplest type of pharmacoeconomic analysis most prescribed drug in Medicine, Surgery and
which compares the cost of equally effective therapeutic Orthopaedics with about 73 % , 92% and 88% prescriptions
options for the given condition is used to define the most while Ranitidine was the most prescribed drug in
economical treatment. Gynaecology department with about 92 % prescriptions.
Table 2. Pre and post intervention FSSG (Frequency Scale
3) The Cost Effectiveness Ratio (Kulkarni et al., 2009) for
for the Symptoms of GERD) score in patients (50
Ranitidine and Pantoprazole was also calculated by dividing
patients/ward)
the cost of treatment by it's clinical outcome, that is, FSSG
score. Ward Frequency Scale for the Symptoms of GERD Questionnaire

4) The FSSG score was calculated from the FSSG questionnaire Reflux Score Dysmotility score Total score

which has a range of questions relating to gastric symptoms Pre Post Pre Post Pre Post
.
like heartburn, burping, etc (Kusano et al., 2004). Orthopaedics 1.56 0.34 1.12 0.40 2.68 0.74
Surgery 2.92 0.51 3.02 1.06 5.94 1.57
Results and discussion
Gynaecology 1.32 0.60 1.88 1 3.20 1.62
There are various brands of antisecretory drugs available in the Medicine 6.74 1.58 6.84 2 13.58 3.58
Average 3.13 0.75 3.21 1.11 6.35 1.87
Indian market. Amongst the Proton Pump Inhibitors ,
Pantoprazole has the highest number with about 350 brands,
The score was assessed based on the FSSG questionnaire
followed by Rabeprazole , Lansoprazole , Esmoprazole and
which included a variety of symptoms ranging from
Omeprazole with 175, 150, 50 and 25 respectively and amongst
heartburn to burping. The FSSG scores calculated pre-
H2 blockers Ranitidine had the highest number with about 35
prescription and post -prescription of antisecretory drugs
brands followed by Famotidine and Roxatidine with 20 and 3
shows that on an average the total pre score was 6.35 which
brands respectively.
significantly reduced to 1.87 post prescription.

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 Asian Journal of Pharmacy and Pharmacology 2017; 3(6): 224-228 226

Table 3. Cost minimisation analysis of the drugs available in The per day cost per decrease in score was Rs.0.12 for
Hospital Pharmacy Pantoprazole and Rs. 0.32 for Ranitidine.

Drugs Cost per Per month Total Per month

Table 6. Average cost effectiveness ratio for orthopaedics
and gynaecology department
Tablet Cost cost/14900 pts
Parameters Pantoprazole (N=44) Ranitidine (N=46)
Pantoprazole Rs.0.78 Rs.23.4 11622
(A)Cost/ 2 Week Rs.10.96 Rs.8.96
Rabeprazole Rs.0.70 Rs.21 10430
FSSG score ( pre prescription ) 2.68 3.18
Omeprazole Rs.0.57 Rs.17.1 8493
FSSG score ( post prescription ) 0.74 1.22
Ranitidine Rs.0.32 Rs.19.2 9536 (B) Difference in FSSG Scores 1.94 1.96
(0.32X2=0.64) A/B 5.62 4.57

Cost minimisation analysis of the drugs available in Hospital Discussion

Pharmacy was carried out using the cost per tablet, per month
We conducted pharmacoeconomic study on 200
cost and the total per month cost for 14,900 patients. It was found
prescriptions containing an antisecretory drugs. In our
that Omeprazole is the cheapest drug available and Pantoprazole
study amongst all the antisecretory drugs; Pantoprazole was
was the costliest drug. Ranitidine is cheaper than Proton pump
the most prescribed drug in Medicine, Surgery and
inhibitors.
Orthopaedics with about 73 %, 92% and 88% prescriptions
Table 4. Cost minimization analysis from the patient's respectively while Ranitidine was the most prescribed drug
perspective ('pocket payments') in Gynaecology department with about 92 % prescriptions.
The combination of Pantoprazole and Domperidone, that is,
Drugs Cost per Tablet Per month Cost
Pan D was prescribed in about 4 % and 2% prescriptions in
Pantoprazole(40/20) Rs.8/5 Rs.240/150 Medicine and Surgery wards. Similar to this other studies
Rabeprazole(20mg) Rs.6.8 Rs.204 also observed that around 51.4% OPD patients and 80%
Lansoprazole(30mg) Rs.4.5 Rs135 Indoor patients are prescribed PPI in their prescriptions
Omeprazole(20mg) Rs.3.5 Rs.105 (Bargade et al., 2016; Solis et al., 2013). The highest
Esmeprazole(20/40mg) 3.5/6 Rs.105 availability of oral and injectable Pantoprazole might be the
reason for this over prescription (as seen in figure 1).
Ranitidine150mg Rs. O.84 Or 1.68 Rs.25.2 Or 50.4
Pantoprazole has the highest number (43%) with about 350
The Cost minimisation analysis calculated from the patient's brands.
perspective: This result showed that Omeprazole is the cheapest This also indicate general tendency among clinicians to
while Pantoprazole was the costliest Proton Pump Inhibitor prescribe latest, more expensive and heavily promoted
available, and Famotidine was the cheapest H2 blocker available. st
agents as their 1 choice of therapy rather than old, less
Table 5. Average cost effectiveness ratio for Pantoprazole and expensive and equieffective drug. There is need to sensitize
Ranitidine in total doctors about cost of drug and rationality of using of PPI.

Parameters Pantoprazole(n=130) Ranitidine(n=61) This study basically observed expenditure on Antisecretory

drugs. When we conducted cost minimisation analysis we
(A) Cost/2 week Rs.10.92 Rs.8.96 found out that Ranitidine and Omeprazole among PPI are
FSSG Score (Pre 10.165 3.18 cheapest drugs. Ranitidine price is low as it is included in
essential drug list and comes under price control (Tripathi,
FSSG Score (post 3.895 1.22
2013; WHO:Essential Medicine List 2017). Ranitidine
(B) Difference in 6.27 1.96 HCL displayed negative price trend (-7.44 percent),
A/B 1.74 4.57 signifying price declines. Celling price of tablet Ranitidine
(150mg) is 0.70 (Gazzette of India, 2017).
Per day reduction in Rs.0.12 Rs.0.32
cost We would also like to highlight the difference among cost of
The Average Cost Effectiveness Ratio was calculated for drug by patient perspective (pocket money) and hospital
Pantoprazole and Ranitidine used in total. It was found that in perspective. Such type of Pharmacoeconomic study also
order to reduce the same unit of FSSG score, Rs.1.74 was help in highlighting the price difference between Generic
required for Pantoprazole while for Ranitidine it was Rs.4.57. drug and branded drugs. As seen in table 3&4 the drug

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 Asian Journal of Pharmacy and Pharmacology 2017; 3(6): 224-228
procured from Hospital pharmacy that is non Branded Generic
are much cheaper than Branded generics drugs available at
medical store and sell at MRP.
Given the superior efficacy of PPIs compared to other acid
inhibiting agents, therapeutic substitution may not be an
acceptable option for many patients (van Pinxteren et al., 2010;
Moayyedi et al., 2008). Therapeutic switching to an equivalent
cheaper or generic PPI would reduce financial burden on the
patients without affecting the quality of patient care. There is
need to start more no of generic stores. It also proved that tertiary
care Hospital can give better efficacy drug with less expenditure.
We also conducted ACER which is other important
pharmacoeconomic parameter. Not only cost but efficacy of
drug is also consider in this type of analysis (Gattani, 2009). As
we had conducted study in our Hospital, we had considered cost
of drug as per hospital formulary. We found that surprisingly
Pantoprazole is more cost effective than Ranitidine. The reason
behind it is the efficacy and compliance of pantoprazole is
better than Ranitidine (Kaspari, 2001; Meneghelli, 2000).
Another reason is Pantoprazole was available at such low cost as
seen in table 3 in our hospital as hospital supplies Generic
Pantoprazole. Similar low cost of PPI were observed by Wenjie
Zeng in China (Wenjie Zeng et al., 2015).
The limitation of this result is baseline score (FSSG) higher in
pantoprazole group. As maximum number of patients from
medicine IPD who are symptomatic had been given this drug. To
overcome this bias we had done analysis between Orthopaedic
and Gynaecology Department where these two drugs are
prescribed equally and where no other drugs were used (Table 1).
Out of 50 patients, 46 and 44 patients were prescribed Ranitidine
and Pantoprazole each. And results indicate that Ranitidine
treatment t is more cost effective with ACER 4.57 as seen in table
6.
Similar to our observation, another studies in primary care
reported initial treatment with a PPI followed by maintenance
therapy with a H2 antagonist to prevent symptomatic recurrence
as the optimal strategy (Goeree et al., 2002) and even treatment
with H2 antagonists was also the optimal strategy for the
prevention of non-steroidal anti-inflammatory drug induced
gastro-intestinal toxicity (Brown et al., 2006).
In other study it was shown that H2 antagonist are the drugs 1 st
indicated in the standard treatment of NSAID gastritis and PPI
are not shown to be superior to them in controlling NSAID
induced gastritis, hence PPI can be reserved for severe or non-
responsive cases to H2 antagonist(Tasneem, 2013). New
Canadian guidelines also states that, prescribing of PPI should be
reduced even without considering economic point of view
(Barbara et al., 2017).
When cost analysis of these two group was compared, there is
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vast difference in the cost of treatment. As per patient
perspective monthly expenditure of even most economical
PPI was twice that of H2 Antagonist (table 4). Thus costs
can be potentially reduced by one half to one quarter with
use of step down therapy.
We also found out that majority of patients were prescribe
maximum therapeutic dose for long duration. Similar
observations were mentioned by Westbrook (Westbrook et
al., 2001). A regular maintenance low dose of most PPIs
will prevent recurrent GORD symptoms in 70-80% of
patients (NHS National Institute for Excellence 2000; NHS
National Institute for Excellence (NICE), 2004; Mason et
al., 2005). Maintenance therapy is indicated for duodenal
ulceration, non-steroidal anti-inflammatory drug (NSAID)
induced ulceration and gastro oesophageal reflux disease
(GERD) (Fahey et al., 2012). Cost of therapy can be
significantly reduced by using maintainance low dose of
PPI. There is need to motivate clinicians to adopt guidelines
or changes in prescribing practices
Conclusion
Therefore, this study helps to choose the most economic
antisecretory drug depending upon the socioeconomic
status of the patient. Therefore, it is important for the doctor
to have knowledge about the drug cost an it's application in
practice would add benefits to the patient. Three scenario
were identified for most cost effective antisecretory
prescribing considering their indication and relative
efficaciousness.
The decrease in drug expenditure can thus be brought about
by:
1) Substitution by Omeprazole or least expensive brand
amongst the Proton Pump Inhibitors.
2) Substitution by Famotidine/H2blockers as per the
Patient's perspective.
3) In case of Pantoprazole, using it's maintenance dose,
that is, 20 mg because most patients do not show
significant gastric symptoms, that is, they have a FSSG
score of less than 8.
Acknowledgement
We would like to thank Dr. Radha Yegnanarayan, Prof. and
Head of Department of Pharmacology for her support and
guidance.
References
Babu MK, Sulthana R, Srinivas M, Praveena M. 2014.
Pharmacoeconomics: Boon or Bane in India.
International Journal of Pharmaceutical and Chemical
Sciences, 3(2):609-12.
 Asian Journal of Pharmacy and Pharmacology 2017; 3(6): 224-228
Bargade MB, Mahatme MS, Hiware S, Admane PD. 2016. Cost-
minimization analysis of proton pump inhibitors in India.
International Journal of Basic & Clinical Pharmacology,
5:1043-7.
Brown T, Hooper L, Elliott R, Payne K, Webb R, Roberts C, et al .
2006. A comparison of the cost-effectiveness of five
strategies for the prevention of non-steroidal anti-
inflammatory drug-induced gastrointestinal toxicity: a
systematic review with economic modelling. Health
Technology Assessment, 10 (38): 1-420.
El-Serag HB, Talley NJ. 2004. Systemic review: The prevalence
and clinical course of functional dyspepsia. Alimentary
Pharmacology & Therapeutics, 19:643-54.
Fahey CT, Tilson L, Teljeur C, Bennett K. 2012. BMC Health
Services Research, 12:408.
Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L,
Rashid FJ, Rojas-Fernandez C, Walsh K, Welch V, Moayyedi
P. 2017. Deprescribing proton pump inhibitors, Evidence-
based clinical practice guideline.Canadian Family Physician,
63 (5) 354-364.
Gattani SG. 2009. Pharmacoeconomics: a review. Asian Journal
of Pharmaceutical and Clinical Research, 2 (3) :15-26.
Goeree R, O'Brien BJ, Blackhouse G, Marshall J, Briggs A, Lad
R . 2002 Cost-Effectiveness and Cost-Utility of Long-Term
Management Strategies for Heartburn. Value in Health, 5 (4):
312-328.
Kaspari S, Biedermann A, Mey J. 2001.Comparison of
Pantoprazole 20 mg to Ranitidine 150 mg b.i.d. in the
Treatment of Mild Gastroesophageal Reflux Disease.
Digestion, 63:163-170.
Kulkarni U, Dalvi K, Moghe VV, Deshmukh Y A. 2009.
Pharmacoeconomics: An emerging branch in health sciences
for decision making. African Journal of Pharmacy and
Pharmacology, 3(8): 362-367.
Kusano M, Shimoyama Y, Sugimoto S, Kawamura O, Maeda M,
Minashi K, Kuribayashi S, Higuchi T, Zai H, Ino K,
Horikoshi T, Sugiyama T, Toki M, Ohwada T, Mori M. 2004.
Development and evaluation of FSSG: frequency scale for
the symptoms of GERD. Journal of Gastroenterology, 39:
888-891.
Mason JM, Delaney B, Moayyedi P, Thomas M, Walt R. 2005.
Managing dyspepsia without alarm signs in primary care:
new national guidance for England and Wales. Alimentary
Pharmacology & Therapeutics, 21 (9): 1135-1143.
Meneghelli UG, Zaterka S, de Paula Castro L, Malafaia O, Lyra
LG. 2000. Pantoprazole versus ranitidine in the treatment of
duodenal ulcer: a multicenter study in Brazil. Am J
www.ajpp.in
228
Gastroenterology. 95(1):62-6.
Moayyedi P, Delaney B. 2008. GORD in adults. BMJ
Clinical Evidence, 6 (403): 1-20.
NHS National Institute for Excellence (NICE) 2000:
Guidance on the use of proton pump inhibitors in the
treatment of dyspepsia. Technology appraisal guidance.
2000, London.
NHS National Institute for Excellence (NICE)2004:
Management of dyspepsia in adults in primary care.
2004, London.
Solis GPJ, Perez PM, Fernandez JP, Maranes AI. 2013.
Inappropriate use of proton pump inhibitors,guidelines
and clinical research. Revista Espanola De
Enfermedades Digestivas, 105:373.
Tasneem Sandozi. 2013. A Comparative Study of Cost
Analysis of H2 Antagonists and Proton Pump Inhibitors
in a Tertiary Care Hospital. Research Journal of
Pharmaceutical, Biological and Chemical Sciences, 4
(1) : 888-897.
Tripathi KD. 2013. Essentials of Medical Pharmacology 7th
Edition. J Am Dent Assoc. Delhi: Jaypee;. Appendix – 2
List of Essential Medicines:957-961.
Van Pinxteren B, Sigterman K, Bonis P, Lau J, Numans
M.2010 Short-term treatment with proton pump
inhibitors, H2-receptor antagonists and prokinetics for
gastro-oesophageal reflux disease-like symptoms and
endoscopy negative reflux disease. Cochrane Database
of Systematic Reviews, 10 (11): CD002095.
Wenjie Zeng, Alexander E Finlayson, Sushma Shankar,
Winnie de Bruyn , Brian Godman. 2015 Prescribing
efficiency of proton pump inhibitors in China: influence
and future directions.BMC Health Services Research,
15:11.
Westbrook JI, Duggan AE, McIntosh JH. 2001.
Prescriptions for antiulcer drugs in Australia: volume,
trends, and costs. BMJ, 323: 1338–9.
WHO: –EML 20th edition (March 2017, amended August
2 0 1 7 ) p d f, 1 . 5 0 M b .
http://www.who.int/medicines/publications/essential
medicines/en/(Published in Part II, Section 3, Sub-
section (ii) of the Gazette of India, Extraordinary)
Government of India Ministry of Chemicals and
Fertilizers Department of Pharmaceuticals National
Pharmaceutical Pricing Authority New Delhi, the 1st
April, 2017.